HomeMy Public PortalAbout5812 AGNES AVE_Electrical__ I 1
WORKERS COMPENSATION DECLARATION CE 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C ) l
I
Policy No - Company FOR APPLICANT TO FILL INJOB
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS
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❑ 1 & 2 Family S Ft $ _ $ LOCALITY t
Certified copy is filed with the county building inspec Y q
tion department Multi family Sq Ft NEAREST
CROSS T Q�
Residential Swimming Pools OWNER OR �p
Date Applicant FIRM NAME b Z 29 C—
CERTIFICATE OF EXEMPTION FROM WORKERSt MAIL
Outlets Rec Light 5w
COMPENSATIONi INSURANCE ADDRESS C CU
eeom completed if the work involved b First 20 y
(This section need not be cp Y Total No Additional CITY I,e Col)T.l No 3 ,
the permit is for one hundred dollars (;100)or less )
PLAN CHECKs
I certify that in the performance of the work for which this APPLICANT
permit is issued I shall not employ any person ,n any manner
so as to become subject to the WorkArs Compensatio Laws 1 Lighting Fixtures First 20 ADDRESS
i Additional- pphcantTotal No CITY Tel No
Date Nixed Appliances Not Over 1 HP PERMIT
NOTIC TO APPLICANT If after making this Certificate of APPLICANT /J
Exemption you should become subject to the Workers Range_ Heater—D W
Compensation provisions of the Labor Code you must forth Oven — Dryer — W M — ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W H —_
deemed revoked Hood Fan _Other—k CITY Tel No /
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Air Cond REG NUMBER Class
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO PROCESSED BYe
and Professions Code and my license is in full force and effect
Size &Type HP KW KVA or K/VAR s- Q O
License Number Lic Class Up to 1 Incl FINAL V
( Contractor Date Over 1 to 10 Incl DATE �(� �� VALIDATION O
❑ Over 10 to 50 Inc! FINAL (Y �! A ' T ~
I am exempt under Sec Over 50 to 100 Inc BY LY
B &P C for this reason Over 100 y Z
Services Swbd MCC & Panelboards N1111, —
Date 0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600 V
❑ } Over 1000 Amp or Over 600 V A
Exemption for Reg Maint Eject
l J SINGLE FAMILY Temp Power Pole 8 Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit 559 3 A
I hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits
Law for the following reason (Section 7031 5 Business and # e o 0 0 0 2
Professions Code) a
❑ I as owner of the property will do the work and the Misc 1Conduits &Conductors 2 0 - 2S,50
structure is not intended or offered for sale (Section ' Other (See Complete Fee Schedule)_
7044 Business and Professions Code) ® e o * 2 5 5 0 C=..,
CONSTRUCTION LENDING AGENCY } _
I hereby affirm that there is a construction lending agency for 10 9274-83
the performance of the work for which this permit is issued PERMIT FEE (Sub Total)
(Sec 3097 Civ C )
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE (� J-6Lender s Address � r
I certify that I have read this application and state that the TOTAL FEE ) �
above information is correct I agree to comply with all County r
ordinances and State laws regulating Electrical wiring and _ {
hereby authorize representatives of this County to enter upon
the above mentioned pro rty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE _
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�svf�.L.[� G�ati-nom z
Signature of Permittee Date
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